Preventive Medicine and the Seven Deadly Sins: Avoiding Discipline Against your Medical License

The final article for the "Seven Deadly Sins" series on avoiding discipline against your medical license will address pride. Pride seemed like such a proverbial "no-brainer" that I decided to save it for the last essay. Little did I know that I would get stuck on pride (a note-to-self moment?). So I conferred with my most trusted source of inspiration, who referred me to the well-known adage of Proverbs 16:18 which reads, "Pride goeth before destruction, and a haughty spirit before a fall." Then I went to my second most trusted source of inspiration, Google, where I was delighted to learn how ecumenical the sin of pride is. That pride is recognized and derided by most religions suggests that pride must be a flaw with which most everyone struggles, but I have a question for you: do certain professions exemplify this sin better than others?

What happens when highly-accomplished personalities find themselves in need of help? Does that translate to a self-perception of failure? Being so unaccustomed to failing, is it thus exponentially more difficult for a physician to ask for help? This is when pride does, in fact, precede destruction.

I know this is neither glamorous, scandalous, nor particularly memorable, but the first thing my colleagues and I thought of as examples of pride had to do with consultations - or more precisely, the failure to obtain a consultation. I guess if you look at it from pride's point of view, a consultation literally requires asking for help. And wait! If you have to ask for help, you might have to admit you don't know it all. Admitting you don't know it all requires ... swallowing ... your ... pride.

I can think of one physician where his pride actually rendered him dangerous. In this particularly egregious case, the physician was not a trained surgeon; however, he took a one-week class in performing liposuction. The training recommended 20 proctored sessions prior to independently performing the procedures, but this physician was so arrogant he felt he did not need this level of oversight. Because the physician was performing the surgery in an outpatient setting, he was able to forego the proctoring requirements. The result: complication after complication. And, to compound this scenario, the physician was too proud to seek help when the complications occurred. One patient suffered from profuse post-operative bleeding. Rather than call an ambulance, or drive the patient to an emergency room, this physician actually tried to check her into a hotel! The hotel refused to accept her so the physician drove her to his home where she bled to death. In cases where we can establish a physician poses an imminent threat to public safety, we are able to seek an interim suspension order (ISO). The ISO prohibits the physician from practicing medicine pending the outcome of legal proceedings seeking to revoke his or her medical license. This physician's license was revoked (after it was suspended), and this case contributed to substantial legislative changes that now pertain to outpatient surgery. It is unfortunate that laws have to be created to counteract such egregious levels of pride.

The standard of medical care is frequently breached when a physician fails to seek a consultation, which is naive on several levels. Consults provide access to quality care for the patient. Consults prevent errors. Averted errors prevent lawsuits. If a lawsuit or complaint is filed, then consults often prevent them from turning into formal action. (Of course, the consult is only really valuable when it is documented [see Sloth]).

The specialty we investigators observe as most susceptible to the consultation omission is pain management. Many physicians dabble in pain management. Many internists, psychiatrists, family physicians and even pediatricians will acquire a patient with an intractable pain condition, and they will get into trouble when they either didn't refer the patient to someone who is well-versed with this specialty, or confer with a pain management physician only when the situation gets too complex. Remember, physicians who practice any specialty are held to the standard of care for that specialty they are practicing, whether they were formally trained or are board certified in that specialty.

Another common challenge for pain management practices is the drug-seeking patient who is quite cunning when it comes to compromising a physician's lack of knowledge. What if the doctor faces the dilemma of the drug-addicted patient who is also suffering from chronic pain? All it takes is a consultation with experts and documentation of such.

Psychiatrists are sometimes conned into prescribing narcotics for pain management. Internists often prescribe psychotropic medications without the appropriate knowledge of their effects. And is it me, or has pharmacology itself become a Pandora's Box of liability? I know many people who are prescribed so many pills, for so many varying ailments, that it's a wonder most physicians know all of what the patient is receiving, let alone how these various medications interact.

Here's another area where we often see problems because of pride. There are a lot of doctors out there who are brilliant practitioners, but they have no business acumen. Being too proud to admit it, they are lured into contracts and obligations due to their business naiveté and end up being cited for all kinds of violations (failing to have a fictitious name permit, aiding/abetting the unlicensed practice of corporate medicine, advertising violations). I hate to be the bearer of bad news, but ignorance is never a valid defense.

And finally, how about the most common demonstration of pride? How about being afraid to ask for emotional help, when the stresses of a busy practice, society's extraordinary expectations, extracting compensation from insurance companies or HMOs, malpractice premiums, complaints, technology, traffic, not to mention the activities of just a normal day, how do most physicians handle that cornucopia of stress? In my line of work, we see the physicians who find it easier to succumb to a panacea of alcohol or drugs than to ask for help. (See "Physician Wellness as Constrained by Burnout" article, November 2007 MBC Newsletter, front page.)

Pride challenges us all to some degree. A healthy sense of self-pride isn't entirely horrifying, and I know in my experience, whenever I exceed a healthy sense of esteem, an omniscient pride-ometer is just waiting to slap me down to reality.

I am proud to have had the opportunity to write these words of caution to you. I hope there is a parcel of information contained within this catalog of sins to help you navigate the investigative process and have a better understanding of what we investigators encounter in our job. Most important, I hope there was some advice within these sins that helps keep someone out of this newsletter! But if I have failed, and if you do end up here, we can consume our pride together and learn from the experience. After all, as C.S. Lewis said, "A proud man is always looking down on things and people; and, of course, as long as you're looking down, you can't see something that's above you."